Provider Demographics
NPI:1902652886
Name:BURSAE, AUDRA
Entity type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:
Last Name:BURSAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-2128
Mailing Address - Country:US
Mailing Address - Phone:201-500-8470
Mailing Address - Fax:
Practice Address - Street 1:92 UNION AVE
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-2128
Practice Address - Country:US
Practice Address - Phone:201-500-8470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-06-25
Deactivation Date:2024-05-14
Deactivation Code:
Reactivation Date:2024-06-25
Provider Licenses
StateLicense IDTaxonomies
NY171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach